Fractures of Femoral N

Neck Intertrochantric FFractures (Pertrochanteric) Subtrochantric

Garden’s classification of femoral neck fractures Intertrochanteric fractures – Kyle classification

(a) Stage I: incomplete (socalled abducted or impacted) – the femoral head in this case is in slight valgus. Types 1 to 4 are arranged in increasing degrees of instability and complexity.
(b) Stage II: complete without displacement. Russel-Taylor Classification
(c) Stage III: complete with partial displacement – the fragments are still connected by the posterior retinacular attachment; the Intertrochanteric fractures are almost always treated by early Type I: Fractures do not extend into piriformis fossa:
femoral head trabeculae are no longer in line with those of the innominate bone.
(d) Stage IV: complete with full displacement – the proximal fragment is free and lies correctly in the acetabulum so that the
internal fixation – not because they fail to unite with conservative Type IA: Lesser trochanter is attached to the proximal fragment
Type IB: Lesser trochanter is detached from the proximal fragment
trabeculae appear normally aligned with those of the innominate. treatment (they unite quite readily), but :
Fracture of neck of femur is an orthopedic emergency due to risk of a vascular necrosis.
necrosis 1- to obtain the best possible position Type II: Fractures that extend into the piriformis fossa:
Type IIA: No significant comminution or fracture of lesser trochanter
1) Initial treatment consists of : 2- to get the patient up and walking as soon as possible thereby Type IIB: Significant comminution of the medial femoral cortex and
- pain-relieving measures reduce the complications associated with prolonged recumbency. loss of continuity of lesser trochanter
- simple splintage of the limb.
A) Conservative treatment : ORIF is the treatment of choice.
- If operation is delayed, a femoral nerve block may be helpful.
- Indication: who are too ill to undergo anaesthesia; Early :
In Garden I , II (impacted fractures) : can be left to unite ,,but safer fixation without reduction
reductio is better. - traction
tion in bed until there is sufficient reductio
reductionn of pain to allow mobilization. - Traction may help to reduce blood loss and pain.
In Garden III , IV ( displaced fractures) : will not unite without internal fixation It is an interim measure until the patient, especially if elderly
and with multiple medical problems, is stabilized and
Indication of operation : B) Surgical treatment : prepared for surgery.
1- In young patients operation is urgent; interrup'on of the blood supply will produce irreversible cellular changes a<er 12 h. 1- Reduction :
2- In older patients also , the longer the delay the greater is likelihood of complications 1) If Postero-medical
medical cortex at lesser trochanter in continuous 1- Reduction : Open reduction
anatomical reduction :
2) Reducation: 2- Fixation: internal fixation :
- Closed reduction .
- IF a stage I, II , fracture
racture is manipulated (closed reduction) , then checked by x-ray.
x (a) an intramedullary nail, with a proximal interlocking
- If fails open reduction & manipulation of the fragments.
- If a stage III or IV , cannot be reduced closed : screw, that can be directed into the femoral head , if :
• If patient under 60 years of age open reduction. 2) If comminuted fracture , where anatomical reduction proves impossible : - the fracture is very comminuted or unstable,
• If pa'ent over 70 years if two careful attempts at closed reduction fail, prosthetic a) valgus osteotomy (non
(non-anatomical reduction) to allow the proximal - if one suspects that operative dissection
di may
replacement : fragment to abut securely against the femoral shaft have compromised bone viability.
1- Hemiarthroplasty , inserted with or without cement. b) Arthroplasty . - preferable for a pathological fracture;
2- Total hip replacement,, If : (b) Dynamic Compression Screw (DCS) -plate
plate device.
(1) if treatment has been delayed for some weeks and acetabular damage is suspected, 2- Fixation: (95 degree)

(2) in pa'ents with metasta'c disease or Paget’s disease. 1) Dynamic Hip Screw (DHS) (135 degree), if troachntric + lesser trochantric fracture (unstable).).
3- Healing :
3) Fixation : 2) Reconstruction Nail, if associated wit
with subtroachntric, shaft & lower femur fracture .
- It's usually associated with non-union.
union.
- with cannulated screws :
3- Healing : - So, additionof of bone grafts may hasten union.
union
• 3 cannulated scews - one screw to support the inferior portion of the neck.
-two
two screw, centrally in level striking the ant. & post. cortices of - The addition of bone grafts may hasten union of the medial cortex.
4- Rehabilitation:
femoral neck. 4- Rehabilitation : patient is allowed partial weightbearing (with crutches)
• Dynamic compression screw ( DCS ) (95 degree) , which attaches to femoral shaft. - Exercises
xercises are started on the day after operation until union is secure.
4) Rehabilitation: - the patient allowed partial weightbearing using crutches.
- From the first day patients should sit up in bed or in a chair. - Breathing Exercise
- Encouraged
ncouraged to begin walking (with crutches or a walker) as soon as possible.

Fractur Shaft of FFemur

Winquist’s classification
The Winquist and Hansen classification is based on comminution;
- fracture instability increase with increasing grades of comminution.
- most useful for determining the need for interlocking nails.
In Type 1: only a tiny cortical fragment. (small insignificant comminution)
In Type 2: the ‘butterfly fragment’ is larger but there is s'll at least 50 %
cortical contact between the main fragments.
In Type 3: the bu6erfly fragment involves more than 50 % of the bone
width.
In Type 4: is a segmental fracture.(no
(no contact between
betw proximal & distal fragm.) It is a poor choice for :
Descriptive Classification
- Open versus closed
- Location: proximal, middle, or distal one-third
one
- Pattern: spiral, oblique, or transverse
- Angulation: varus, valgus, or rotational deformity
- Displacement: shortening or translation
- Comminuted, segmental, or butterfly fragment
Emergency treatment
The risk of systemic complications in these high energy energies
can be significantly reduced by early stabilization of the fracture:
3- Traction with a splint :
is first aid for a patient with a femoral shaft fracture. It is applied
at the site of the accident, and before the patient is moved.
4- A Thomas’ splint:
This temporary stabilization helps to control pain, reduces
bleeding and makes transfer easier.
5- Shock should be treated; blood volume is restored and
maintained, and a definitive plan of action instituted as soon
as the patient’s condition has been fully assessed.
Definitive treatment
In the multiply injured patient:
Stabilization
tabilization with an external fixator the fixator can be exchanged for an intramedullary nail
when the patient’s condition stabilizes.
- The timing of this second procedure is problematic :
Some guidance can be sought from measurement of circulating levels of interleukin-6, a pro-
inflammatory cytokine when the levels start to decrease, it should be safe to perform
‘second hit’ interven'ons. Clinically this occurs around 55–7 days a<er admission.
A) Conservative treatment :
Traction, bracing and spica casts :
- Traction can reduce and hold most fractures in reasonable alignment,
except those in the upper third of the femur.
The chief drawback is :
The length of 'me spent in bed (10
(10–14 weeks for adults) with the a6endant
problems of keeping the femur aligned until sufficient callus has formed.
To over come this drawback : by changing to a (around 6–8 weeks) :
- Plaster spica or –
- Functional bracing – in the case of lower third fractures – when the fracture is
‘sticky’.
The main indications for traction are :
- fractures in children;
- contraindications to anaesthesia; and
- lack of suitable skill or facilities for internal fixation.
- elderly patients,
- for pathological fractures and
- for those with multiple injuries.
A) Traction in children
For young children, skin traction without a splint is usually all that is needed.
• In newborn: (assess child abuse) : "Crede's method"
- Femur reduced & fixed by tongue depressor and thigh flexed on
abdomen and fixed to it for 2 weeks by adhesive plaster.
• Infants ( <4 years ) less than 12 kg in weight: "Gallows tracAon"
- are most easily managed by suspending the lower limbs enough to
raise the buttocks from the bed. (but no > 2 kg used)
• Older children ( 5 – 15 years ) :
- are better suited to Russell’s traction or use of a Thomas’ splint.
- Fracture union will have progressed sufficiently by 2–4 weeks (depending
on the age of the child) to permit a hip spica to be applied and the child is
then allowed up.
- Consolidation is usually complete by 6–12 weeks.
B) Traction in Adults :
Not performed except in certain situations as: those very ill for anesthesia
1- Adults require skeletal traction (8–10 kg for an adult) through a pin or a
tightly strung Kirschner wire behind the tibial tubercle.
2- The limb is usually supported on a Thomas’ splint .
skeletal traction without a splint (Perkins’ traction) has the advantages
of producing less distortion of the fracture
Rehabilitation :
- While the patient is in traction, joint mobility must be preserved by
encouraging movement & exercise.
Monitoring :
Thee position of the fragment should be checked repeatedly by xx-ray.
Immobilization following the traction :
Once the fracture is sticky (at about 8 weeks in adults) traction is replaced by :
- Cast or brace , and the patient allowed up and partial weightbearing.
- For fractures in the upper half of the femur, plaster spica is the safest but it will
almost certainly prolong the period of knee stiffness.
- For fractures in the lower half of the femur, cast-bracing is suitable.
This type of protection is needed until the fracture
re has consolidated (16–24
(16 week)
A) Surgical treatment : ORIF
1-- Reduction : Open reduction
2-- Fixation : Internal fixation
1- Interlocking Intramedullary nail
- It is the method of choice for most femoral shaft fractures.
- It controls rotation and length, and ensures stability even for
subtrochanteric and distal third fractures.
2- Plate and screw fixation : The main indications for plates are :
- fractures at either end of the femoral shaft, especially those with
extensions into the supracondylar or pertrochanteric areas,
- a shaft fracture in a growing child, ( we can better used non-rigid
non Nancy nail )
- a fracture with a vascular injury which requires repair.
Usually not used because :
• Long skin incision will be needed
• Many screws will be needed above & below fracture site.
3- Reconstruction Nail: indication :
- if associated with trochantric , subtroachntric & lower femur fractures .
- If segmental stracture as no 2 plates in same fracture.
Healing: Fracture usually heals within 20 weeks
3-- Rehabilitation :
- The patient is allowed up as soon as he or she is comfortable and knee
movement exercises are encouraged to prevent tethering by the half pins.
- Partial weightbearing is usually possible immediately but this will depend on
the x-ray appearance of callus – this may take some 'me (more than 6 weeks)
External fixation , The main indications for external fixation are
(1) treatment of severe open injuries;
(2) management of pa'ents with mul'ple injuries
juries where there is a need to
reduce operating time and prevent the ‘second hit’; and
(3) the need to deal with severe bone loss by the technique of bone transport.
(4) trea'ng femoral fractures in adolescents
Treatment of open fractures
Open femoral fractures should be carefully assessed for
(1) skin loss; (2) wound contamina'on;
(3) muscle ischaemia; and (4) injury to vessels and nerves.
- The immediate treatment is similar to that of closed fractures;
- In
I addition, the patient is started on intravenous antibiotics.
• The wound will need cleansing
• Stabilization of open femoral shaft fractures :
- is best achieved with locked intramedullary nails
- Unless there is heavy contamination or bone loss – in which case
external fixation is preferable. ( This only used in our hospital )

Supracondylar Fracture
ractures
Conservative Surgery
Indications : B-Surgery Operative treatment with internal fixation can enable accurate fracture
1- if the patient is young or (Elderly pa'ents tend not do as well with the 6 weeks of enforced reduction, especially of the joint surface, and early movement.
recumbency.) 1- Reduction : Open reduction
2- the facilities and skill to treat by internal fixation are absent.
2- Fixation: internal fixation :
1- Closed reduction (by traction):
a- If the fracture is only slightly displaced and extra-articular
extra articular or 1. For the type A &
If it reduces easily with the knee in flexion : - Locked intramedullary nails, which are introduced retrograde through the intercondylar notch
- It can be treated satisfactorily by skeletal traction through the proximal tibia; 2. For type B fractures (single condylar fracture):
The AO classification of supracondylar fractures
Type A : Extra-articular fractures have no articular splits and are truly - The limb is cradled on a Thomas’ splint with a knee flexion piece and movements - held with Kirschner wires preparatory to inserting Compression Screws (CS)
‘supracondylar’.
Type A1: Simple, two-part supracondylar fracture
are encouraged. 3. Simpler
impler type C fractures (T or Y shaped fracture ):
Type A2: Metaphyseal wedge - Locked intramedullary nails, which are introduced retrograde through the intercondylar notch
Type A3: Comminuted supracondylar fracture b- If the distal fragment is displaced
displa by gastrocnemius pull :
Type B : Uni-Condylar fractures are simply shear fractures of one of the
a second pin above the knee, and vertical traction, will correct this. - Or best fixed with a Dynamic (95 degree) condylar screw and plate.
condyles; and
Type B1: Lateral condyle, sagi6al 4. For severely comminuted type C fractures
Type B2: Medial condyle, sagi6al - Locked intramedullary nails, which are introduced retrograde through the intercondylar notch
Type B3: Coronal 2- Immobilization & rehabilitation :
Type C: Bi-Condylar fractures have supracondylar and intercondylar fissures . - At 4–6 6 weeks, when the fracture is beginning to unite, traction can be they provide adequate stability, even in the presence of osteoporotic bone,
Type C1: Noncomminuted supracondylar “T” or “Y” fracture
Type C2: Comminuted supracondylar fracture replaced by a cast-brace and N.B Reconstruction Nail, if associated with trochantric , subtroachntric & shaft fractures.
Type C3: Comminuted supracondylar and intercondylar fracture - the patient allowed up and partially weightbearing with crutches. Dynamic Compression Screw (DCS) , can also used (remember the indication of this screw )
rehabilitation :
- Unprotected
tected w
weight bearing is not permitted until thee fracture have
consolidated
lidated ( usually around 12 weeks).